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R E S E A R C H Open AccessFive-year effect of community-based intervention Hartslag Limburg on quality of life: A longitudinal cohort study Saskia PJ Verkleij1*, Marcel C Adriaanse1, WM

R E S E A R C H Open Access

Five-year effect of community-based intervention Hartslag Limburg on quality of life: A longitudinal cohort study

Saskia PJ Verkleij1*, Marcel C Adriaanse1, WM Monique Verschuren2, Eric C Ruland3, Gerrie CW Wendel-Vos2, Albertine J Schuit1,2

Abstract

Background: During the past decade, quality of life (QoL) has become an accepted measure of disease impact, therapeutic outcome, and evaluation of interventions So far, very little is known about the effects of based interventions on people’s QoL Therefore, the effect of an integrative cardiovascular diseases community-based intervention programme‘Hartslag Limburg’ on QoL after 5-years of intervention is studied

Methods: A longitudinal cohort study comparing 5-year mean change in QoL between the intervention (n = 2356) and reference group (n = 758) QoL outcomes were the physical and mental health composite scores (PCS and MCS) measured by the RAND-36 Analyses were stratified for gender and socio-economic status (SES)

Results: After 5-years of intervention we found no difference in mean change in PCS and MCS between the intervention and reference group in both genders and low-SES However, for the moderate/high SES intervention group, the scales social functioning (-3.6, 95% CI:-6.1 to -1.2), physical role limitations (-5.3, 95% CI:-9.6 to -1.0), general mental health (-3.0, 95% CI:-4.7 to -1.3), vitality (-3.2, 95% CI:-5.1 to -1.3), and MCS (-1.8, 95% CI:-2.9 to -0.6) significantly changed compared with the reference group These differences were due to a slight decrease of QoL

in the intervention group and an increase of QoL in the reference group

Conclusion: Hartslag Limburg has no beneficial effect on people’s physical and mental QoL after 5-years of

intervention In fact, subjects in the intervention group with a moderate/high SES, show a decrease on their mental QoL compared with the reference group

Introduction

During the past decade there has been growing interest

in measuring people’s quality of life (QoL) Traditionally,

outcome measurements in health care have mostly been

determined by objective medical evaluation [1] The

interest in assessing QoL stems from recognition of the

importance of patients’ own perception of their health

status and well-being QoL has become an accepted

measure of disease impact, therapeutic outcome, and

evaluation of interventions

Chronic diseases often affect people’s QoL Research

shows that people with diabetes mellitus type 2, obesity,

and cardiovascular diseases (CVD) have an decreased

QoL [2-5] Moreover, people with favourable levels of CVD risk factors have greater longevity and tend to have a better QoL [2] Therefore, health promotion may not only stimulate a healthy lifestyle but may also improve people’s QoL A widely advocated strategy in public health is community-based health promotion

In 1998, a community-based CVD prevention program was initiated in the Netherlands, in the Maastricht region of the province of Limburg The goal of Hartslag Limburg, Dutch for Heartbeat Limburg, is to reduce the CVD risk by a reduction in fat intake, an increase in physical activity, and smoking cessation [6-9] Hartslag Limburg and other community-based prevention pro-grams have been proven effective in reducing cardiovas-cular and lifestyle risk factors [9-12] However, until now the effects of community-based interventions on

* Correspondence: saskiaverkleij@live.nl

1 Department of Health Sciences VU University, Amsterdam, the Netherlands

Full list of author information is available at the end of the article

© 2011 Verkleij et al; licensee BioMed Central Ltd This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in

people’s QoL are not known This is striking because

QoL is a clinically important outcome of people’s

per-spective on well-being Therefore, the aim of the present

study was to investigate the effect of Hartslag Limburg

on QoL after 5-years of intervention

Methods

Hartslag Limburg

In 1998, the community-based intervention project

Hartslag Limburg started The aim of the project was to

decrease the prevalence of CVD in the general

popula-tion of the Maastricht region (populapopula-tion 185,000) by

encouraging the inhabitants to become physically active,

reduce their fat intake, and quit smoking Hartslag

Lim-burg, incorporated two strategies: 1) a population

strat-egy aimed at all inhabitants and specifically at low SES

groups, and 2) a high-risk strategy focusing on

indivi-duals diagnosed with CVD or multiple CVD risk factors

(e.g hypertension, cholesterol, and overweight) [9] The

main partners in the community project are the city

councils of Maastricht and four adjacent municipalities,

the Regional Public Health Institute Maastricht (RPHI),

two community social work organizations, and the

regional community healthcare organization

Collabora-tion among these partners is achieved through nine

local health committees that organize activities which

promote and facilitate healthy lifestyles From 1999 until

2003, a total of 790 interventions have been

implemen-ted, of which 590 were major interventions (193 diet,

361 physical activity, and 9 antismoking) Almost 50% of

the interventions took place in low-income areas

Exam-ples of activities include computer-tailored nutrition

education, nutrition education tours in supermarkets,

public-private collaboration with the retail sector,

televi-sion programs, food labeling, smokefree areas, creating

walking and bicycling clubs, walking and cycling

cam-paigns, and a stop-smoking campaign, in addition to

commercials on local television and radio, newspaper

articles, and pamphlet distribution A more detailed

description of the project is available elsewhere [8]

Ethics approval

This study was approved on 18 August 1998 by the

Dutch Medical Ethics Committee TNO Chairman of

committee: Dr C.H.M Kleemans Letter of reference;

CO/TW 2599/10049

Study population

In this study, a cohort design was used to investigate

the effect of the intervention Changes observed in the

intervention group were compared with changes in a

reference group The study population of both

inter-vention and reference area originated from two former

monitoring studies conducted by the Dutch National

Institute for Public Health and the Environment [13,14]

The source population of the intervention region con-sisted of 13,184 men and women From this group a gender- and age-stratified sample of 4,500 subjects was selected This was done because the aim was to include

at total of 3,000 subjects in the baseline measurement

A response rate of at least 65% was anticipated based on previous experiences Of the selected 4,500 sample, 441 men and women were excluded because they had moved to another region The remaining 4,059 subjects were invited to participate 3,232 (80%) whished to par-ticipate in the study, but for economical and logistical reasons we were forced to include 3,000 subjects only

So the remaining 232 subjects that reported their inter-est in the study were excluded after the 3000 was reached Of these 3,000 subjects, 2,414 (81%) partici-pated in the 5-year follow-up measurement in 2003 In order to standardize the difference in age range in the two populations, participants younger than 30 years were excluded (n = 58) from the intervention popula-tion Therefore, we analysed the data of 2,356 subjects from the intervention region

The source population in the reference region was smaller, and for this reason all subjects were included in the study These subjects participated in an ongoing cohort (the Doetinchem cohort), in which all partici-pants were physically examined in 1998 and 2003 In

1998, a total of 1,115 were invited, of which 895 subjects participated (80%) Of these 895 subjects, 758 subjects (85%) participated in the follow-up measurement in 2003

In total, analyses were performed on a population of 3,114 (2,356 in the intervention region and 758 in the reference region) men and women aged 31 to 70 years Participants from both the reference and intervention areas were informed that the aim of the study was to monitor change in risk factors in adults over a 5-year period Thus, they were not aware of the underlying aim

of the present study The study population has been described in more detail elsewhere [9]

Data Collection

The measurements performed in the intervention and reference group consisted of identical standardized methods In the reference area, data collection started in January and lasted until December of the same year In the intervention area, data collection started in August (same year as reference group) and lasted until February the next year The measurements included a physical examination at the Regional Public Health Institute and

a self-administered questionnaire The staff that per-formed the physical examination in the intervention region was not blinded for the goal of the study, but

they were unaware of the values of the pre-intervention

measurement when conducting the post-intervention

measurement The self-administered questionnaire

con-sisted of questions on demographics, health status, QoL,

current smoking, physical activity, diet, and chronic

dis-eases During the physical examination, blood pressure

(systolic and diastolic), height, weight, waist

circumfer-ence, and total and HDL cholesterol concentration were

measured

Quality of life

QoL was measured by the Dutch version of the

RAND-36 Health Survey (RAND-RAND-36) [15], which was translated

from the standardized SF-36 Health Survey [16] The

RAND-36 consists of 36 questions which comprises of

eight multi-item scales: physical functioning, social

func-tioning, role limitations due to physical health problems,

role limitations due to emotional problems, general

men-tal health, vimen-tality, bodily pain, and general health

percep-tion In addition, two summary scores representing

physical (PCS) and mental health (MCS) are generated

All scales were scored from 0 to 100, with higher scores

indicating a better QoL [17] The RAND-36 is a

vali-dated, reliable, and responsive measure with good

psy-chometric properties [18] The RAND-36 comprises of

the same items as the SF-36 [19], however, the

methodol-ogy to derive the final scores is different, but the effect on

the final score is minimal [16] It is suggested that a

mini-mum of three to five points difference on any given scale

may be considered clinically important [20]

Risk factors and diseases

Socio-economic status (SES) was defined by the highest

level of education that was completed Education was

measured on a nine-point ordinal scale ranging from

elementary school to completed university Low

socio-economic status was defined as lower vocational or

pri-mary school Current smoking status was assessed by

asking the respondents whether they had smoked the

last seven day (yes/no) Participants that indicated that

they did smoke were categorized as smoker Body mass

index (BMI) was calculated as weight divided by height

squared (kilograms per square meter) In this calculation

one kilogram was subtracted from the measured weight,

in order to adjust for the light indoor clothing Presence

of diseases at baseline was based on self-reported

preva-lence of one of the following diseases: myocardial

infarc-tion, stroke, cancer, or diabetes mellitus type 2 The

occurrence of diseases between baseline and follow-up

is determined by the absence of a disease at baseline

and the self-reported presence of one or more of the

above mentioned diseases at follow-up

Statistical analysis

Descriptive data (means, standard deviation, and

percen-tage) of the baseline characteristics of the intervention

and reference population were presented for men and women separately First, differences in study sample characteristics of the intervention and reference popula-tion by sex were examined using Students t-test for con-tinuous variables and c2

-tests for categorical variables Next, the effect of Hartslag Limburg on QoL was inves-tigated by comparing change in the two summary RAND-36 scores, PCS and MCS, between the interven-tion group and the reference group using regression analyses The dependent variable is change in PCS and MCS Group status (intervention/reference) is the inde-pendent variable The analyses were performed sepa-rately for men and women and adjusted for age, SES, presence of chronic diseases at baseline, occurrence of chronic diseases between baseline and follow-up, and mean of baseline and follow-up measurement of the variable under study This last adjustment was done to neutralize possible effects of regression to the mean [21] Finally, since Hartslag Limburg has a specific focus

on low-SES groups, additional regression analyses were also stratified for SES For all statistical testing, we used two-sided hypothesis testing with an alpha level of < 0.05 Data were analysed using SAS software version 9.1

Results Study population

Baseline characteristics of men and women measured in

1998 for the intervention and the reference population who completed follow-up in 2003 are shown in Table 1 Mean age of both populations was approximately 51 years There were no significant differences in baseline characteristics in women between the two populations However, men in the intervention group were younger, scored significantly lower on prevalence of cancer, vital-ity, and general health perception than men in the refer-ence group Additional analysis showed that at follow-up, responders (n = 3,114) (the total number of subjects with

a pre- and post intervention measurement (intervention

n = 2,356 and control n = 758)) compared with non-responders (n = 682) scored higher on baseline PCS (50.4

vs 49.0) and MCS (50.3 vs 48.9), whereas no differences were found regarding age, gender, and SES

Effect on QoL after 5-years

The mean and adjusted difference in change in QoL among men and women in the intervention and the reference group after 5-years of intervention are pre-sented in Table 2 After 5-years of intervention we found no difference in mean change in both PCS and MCS between the intervention and reference group across gender For women, the differences between intervention and reference group were significant on the subscales social functioning (mean change between intervention and reference group -4.3, 95% CI: -6.9 to

-1.7), vitality (-3.0, 95% CI: -4.9 to -1.1), and bodily pain

(-2.8, 95% CI: -5.5 to -0.2) For men there were no

sig-nificant differences between the intervention and the

reference group on any of the eight subscales, nor on

the summary PCS and MCS scales

Social economic status

The mean change and adjusted difference in change in QoL among low and moderate-high SES groups in the intervention and reference group after 5-years of inter-vention are presented in Table 3 In the low SES

Table 1 Baseline characteristics stratified by sex of intervention and reference population (1998) who completed follow-up in 2003

Intervention (n = 1187)

Reference (n = 349)

Intervention (n = 1169)

Reference (n = 409) Demographics

Age (years) 50.6 (9.8)* 52.2 (9.9) 50.6 (9.7) 51.3 (10.4) Low socio-economic status (%) 44.6 43 60.7 61.3 Current smoking (%) 23.9 24.7 26.7 22 BMIaoverweightb(%) 64 60 48 51 Diseases (self reported)

Myocardial infarction (%) 3.1 3.4 0.7 0.7

Diabetes mellitus (%) 2.9 1.4 1.5 2.2 Quality of Life

Physical functioning (PF) 89.2 (15.5) 89.7 (16.0) 85.0 (17.7) 85.9 (18.6) Social functioning (SF) 88.6 (19.0) 90.2 (16.4) 84.7 (21.0) 82.6 (21.9) Role limitations physical (RP) 86.8 (28.6) 86.9 (27.2) 80.2 (35.2) 78.9 (34.7) Role limitations emotional (RE) 89.4 (26.8) 91.3 (22.7) 85.4 (31.9) 85.4 (31.1) General mental health (MH) 78.7 (15.6) 80.0 (13.5) 73.3 (16.9) 74.3 (15.1) Vitality (VT) 68.9 (17.6)* 70.9 (15.8) 63.5 (18.3) 63.5 (16.9) Bodily pain (BP) 84.7 (21.0) 86.7 (18.2) 79.5 (23.4) 78.2 (21.5) General health perception (GH) 69.5 (17.2)* 72.7 (15.9) 68.1 (18.1) 69.4 (17.2) MCSa 51.3 (9.0) 52.2 (7.9) 49.1 (10.0) 49.0 (9.5) PCSa 51.0 (7.4) 51.5 (7.4) 49.6 (8.9) 49.5 (9.1)

*Difference between intervention and reference group (p < 0.05) (bolded) Data presented as mean (SD) or as percentage.

a

BMI, Body mass index; MCS, Mental Health Composite score of RAND-36; PCS, Physical Health Composite score of RAND-36.

b

Overweight was defined as body mass index of ≥ 25 kg/m 2

.

Table 2 Mean change in QoLaby sex after 5-years of intervention

Intervention Reference Adj differenceb(95% CI)c Intervention Reference Adj differenceb(95% CI)c

PFa -0.6 -1.7 0.7 (-1.0 to 2.4) -1.6 -2.3 0.7 (-1.1 to 2.5)

SFa -0.9 -0.1 -0.9 (-3.3 to 1.5) -0.9 3.4 -4.3* (-6.9 -1.7)

RPa -2.0 0.3 -2.7 (-6.7 to 1.3) -3.7 0.4 -4.1 (-8.7 to 0.6)

RE a -1.0 0.3 -1.2 (-5.0 to 2.6) -0.4 0.0 -0.3 (-4.7 to 4.0)

MH a -0.5 1.0 -1.5 (-3.1 to 0.2) 0.0 1.5 -1.6 (-3.3 to 0.2)

VT a -0.4 0.0 -0.5 (-2.4 to 1.5) -0.5 2.5 -3.0* (-4.9 to -1.1)

BP a -1.6 -3.6 1.7 (-0.8 to 4.3) -2.4 0.4 -2.8* (-5.5 to -0.2)

GH a -2.6 -3.7 0.9 (-0.9 to 2.6) -2.8 -2.3 -0.8 (-2.5 to 1.0) MCS a -0.2 0.7 -0.8 (-1.8 to 0.3) 0.2 1.3 -1.1 (-2.3 to 0.1) PCS a -0.7 -1.3 0.5 (-0.4 to 1.4) -1.2 -0.7 -0.6 (-1.5 to 0.4)

*Difference between intervention and reference group (p < 0.05) (bolded).

a

QoL, quality of life; PF, physical functioning; SF, social functioning; RP, role limitations physical; RE, role limitations emotional; MH, general mental health; VT, vitality; BP, bodily pain; GH, General health perception; MCS, Mental Health Composite score of RAND-36; PCS, Physical Health Composite score of RAND-36 between baseline and follow-up, and the mean of baseline and follow-up of the variable under study.

b

Adjusted difference in change between the intervention and the reference group for age, level of education, presence of self reported diseases (myocardial infarction, stroke, cancer, diabetes mellitus) at baseline (1998), occurrence of diseases (myocardial infarction, stroke, cancer, diabetes mellitus).

c

intervention group (n = 1,239), physical functioning

decreased significantly less (1.9, 95% CI: 0.0 to 3.8)

dur-ing follow-up compared with the reference group (n =

401) For the moderate or high SES intervention group

(n = 1,117), the scales social functioning (-3.6, 95% CI:

-6.1 to -1.2), physical role limitations (-5.3, 95% CI: -9.6

to -1.0), general mental health (-3.0, 95% CI: -4.7 to

-1.3), vitality (-3.2, 95% CI: -5.1 to -1.3), and MCS (-1.8,

95% CI: -2.9 to -0.6) significantly changed compared

with the reference group (n = 357) These differences

were due to a slight decrease of QoL in the intervention

group compared with a slight increase of QoL in the

reference group

Discussion

This study focused on exploring the effect of a

commu-nity-based prevention program on people’s QoL This is,

to our best knowledge, the first study that prospectively

determined the effect of a CVD community-based

inter-vention (Hartslag Limburg) on people’s QoL We

con-cluded that Hartslag Limburg has no beneficial effect on

people’s physical and mental QoL after 5-years of

inter-vention Only for women, differences between

interven-tion and reference group were significant for the

subscales social functioning, vitality, and bodily pain In fact, subjects in the moderate/high SES intervention group, show a decrease on their mental health compo-site score compared with the reference group These dif-ferences were due to a slight decrease of QoL subscales social functioning, general mental health and vitality in the moderate/high SES intervention group and an increase of those three QoL subscales in the reference group

Several outcomes of the effects of the program Hartslag Limburg have already been reported Hartslag Limburg was not effective in changing smoking behaviour [22], but was effective in reducing other cardiovascular and lifestyle risk factors (e.g BMI, blood pressure, energy intake, and time spent on walking) [9,12] In this study,

we anticipated a small decrease in the QoL in both groups (due to ageing), being less pronounced in the intervention group However, this was not observed On the contrary, the present study found a non-significant tendency for a reduction in QoL in the intervention group, and an improvement of QoL in the control group (six of the eight scales for women and four of the eight scales for men) Apparently the beneficial changes in CVD risk factors associated with the intervention

Table 3 Mean change in QoL among low and moderate-high SESagroups after 5-years of intervention

QoL Low SESa Moderate or high SESa

Baseline

Ia

(n = 1239)

Baseline

Ra (n = 401)

Mean change

Ia

Mean change

Ra

Adj diff b

(95% CI)c

Baseline

Ia (n = 1117)

Baseline

Ra (n = 357)

Mean change

Ia

Mean change

Ra

Adj diff b

(95% CI)c

PF a 83.8 (18.6) 85

(20.1)

-0.9 -3.1 1.9*

(0.0 to 3.8)

90.9 (13.4) 90.6 (13.7) -1.2 -0.8 -0.7

(-2.3 to 0.8)

SFa 84.8 (21.6) 84.2 (21.2) 0.2 1.9 -1.9

(-4.4 to 0.6)

88.9 (18)

88.2 (18.1) -2.1 1.6 -3.6*

(-6.1 to -1.2)

RFa 80.7

(34)

81.1 (34.1) -2.2 -0.9 -1.8

(-6.2 to 2.6)

86.9 (29.6) 84.3 (28.8) -3.4 1.7 -5.3*

(-9.6 to -1.0)

RE a 86

(31)

87.9 (28.1) 0.0 -1.4 1.3

(-2.8 to 5.3)

89.2 (27.3) 88.4 (27.2) -1.6 1.8 -3.2

(-7.4 to 0.9)

MHa 74.2 (17.4) 75.3

(15.8)

0.2 0.4 -0.2

(-2.0 to 1.5)

78.2 (14.8) 78.7 (13.1) -0.8 2.3 -3.0*

(-4.7 to -1.3)

VT a 64.7 (18.8) 65.6 (17.1) -0.2 0.3 -0.6

(-2.5 to 1.4)

68 (17.2)

68.4 (16.4) -0.7 2.4 -3.2*

(-5.1 to -1.3)

BP a 79.5 (23.7) 79.5 (22.6) -1.8 -1.1 -0.7

(-3.4 to 1.9)

85.1 (20.3) 85

(17.4)

-2.3 -1.8 -0.6

(-3.1 to 2.0)

GHa 66.8 (18.1)* 68.9 (17.9) -2.8 -3.1 0.0

(-1.7 to 1.8) 71.2 (16.8)* 73.2

(15)

-2.7 -2.8 0.0

(-1.8 to 1.8) MCS a 49.7 (10.1) 50.0

(9.2)

0.4 0.6 -0.2

(-1.3 to 0.9)

50.9 (8.9)

50.9 (8.7)

-0.4 1.5 -1.8*

(-2.9 to -0.6) PCSa 49.2

(8.7)

49.4 (9.1)

-0.9 -1.0 0.0

(-0.9 to 1.0)

51.7 (7.4)

51.6 (7.3)

-1.0 -0.9 -0.2

(-1.1 to 0.7)

*Difference between intervention and reference group (p < 0.05) (bolded).

a

SES, socio-economic status; QoL, quality of life; I, Intervention region; R, Reference region; PF, physical functioning; SF, social functioning; RP, role limitations physical; RE, role limitations emotional; MH, general mental health; VT, vitality; BP, bodily pain; GH, General health perception; MCS, Mental Health Composite score of RAND-36; PCS, Physical Health Composite score of RAND-36.

b

Adjusted difference in change between the intervention and the reference group for age, gender, presence of diseases (myocardial infarction, stroke, cancer, diabetes mellitus) at baseline (1998), occurrence of diseases (myocardial infarction, stroke, cancer, diabetes mellitus) and between baseline and follow-up, and the mean of baseline and follow-up of the variable under study.

c

95% CI, 95% confidence interval.

program did not translate into a better perceived QoL.

Maybe the cardiovascular and lifestyle risk changes were

too modest to influence people’s QoL Seasonality can

not explain the outcome of the study, because the

pre-and post intervention measurement of subjects in

inter-vention and control group took place in the same month

Research has shown that SES is associated with

(self-rated) health status [23] Since Hartslag Limburg has a

specific focus on low SES groups, analyses were

strati-fied for SES Previous analyses showed that Hartslag

Limburg beneficially affected BMI, waist circumference,

blood pressure, energy intake, fat intake, walking, and

bicycling in low SES groups [9,12] Hence, we

particu-larly anticipated an effect on QoL in this group

How-ever, except for physical functioning no effects were

observed in the low SES group

Community-based CVD prevention programs are a

widely advocated strategy in public health So far, no

studies have reported on the effects of community-based

interventions on QoL There is also limited data on the

effect of health promotion programs and QoL

Compari-son of outcomes is difficult because of differences in

time periods over which the effects were measured, used

methods, interventions, and study populations Yet,

there are some related studies that put our results in

perspective Improvement in the mental component of

QoL has been reported after a cardiovascular lifestyle

modification program of one year [24] Also Lobo et al

found less impairment in QoL in the intervention group

compared with a control group after an intervention

program of 21 months [25] The only study that also

did not report a beneficial effect of a lifestyle program

on QoL is the study of Cupples & McKnight, who

inves-tigated the effect of a 2-year health promotion program

five years after enrolment in patients with angina [26]

However, these studies all focused on patients at high

cardiovascular risk and were based on individually

tar-geted interventions

The strengths of our study are the longitudinal design,

the use of a reference group, a large sample of subjects,

and a follow-up of 5 years The large number of

partici-pants included in this study ensures enough power to

detect small differences Finally, we used the RAND-36,

which is a validated, reliable, and responsive

question-naire to measure QoL [18]

This study also has some limitations that should be

addressed First, the number and selectiveness of

drop-outs may have biased the results In our study,

respon-ders scored higher on baseline PCS and MCS compared

with non-responders at the follow-up No differences

between non-responders and responders were found in

age, gender, and SES In this study however, over 80%

of the subjects completed both the baseline and the

5-year follow-up measurement So, it is not likely that

drop-out might have changed our results Second, it is well known that presence of chronic diseases can nega-tively effect people’s QoL [3-5] Therefore, the results of our study were adjusted for the presence or occurrence

of myocardial infarction, stroke, cancer, and/or diabetes mellitus type 2 Unfortunately, no information was avail-able about all chronic diseases (e.g chronic obstructive pulmonary disease (COPD), depression and inflamma-tory bowel diseases) So, we could not control for them However, the percentage of people in our study popula-tion, who are suffering from COPD and/or inflammatory bowel diseases, would probably be low So, it is not likely to influence our results to a great extent

In summary, this study showed that five years of com-munity-based prevention did not lead to an improvement

in QoL In fact, subjects in the intervention group with a moderate/high SES, show a decrease on their mental QoL compared with the reference group Although the health effects of Hartslag Limburg and other community based intervention have been previously established, this study does not provide an indication that these types of programs should be implemented to favourably improve the QoL in the general population

Conclusion

We found that Hartslag Limburg has no beneficial effect

on people’s physical and mental QoL after 5-years of intervention No substantial effects were observed in men and women However, people in the intervention group with a moderate or high SES had a relative decrease in mental QoL compared to their peers in the reference group

Author details

1 Department of Health Sciences VU University, Amsterdam, the Netherlands.

2

National Institute for Public Health and the Environment, Bilthoven, the Netherlands 3 Netherlands Institute for Health Promotion and Disease Prevention, Woerden, the Netherlands.

Authors ’ contributions SPJV prepared the article and performed the data-analyses MCA contributed

to writing the article AJS was project leader of Hartslag Limburg and contributed to writing the article GCWW performed the project coordination of Hartslag Limburg and contributed to writing the article ECR conceived the study and was project leader WMMV was project leader of the Doetinchem cohort All authors have read and approved the final version of the article.

Competing interests The authors declare that they have no competing interests.

Received: 12 March 2010 Accepted: 27 February 2011 Published: 27 February 2011

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doi:10.1186/1477-7525-9-11 Cite this article as: Verkleij et al.: Five-year effect of community-based intervention Hartslag Limburg on quality of life: A longitudinal cohort study Health and Quality of Life Outcomes 2011 9:11.

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